POS0234 HOW CLOSELY DO GERMAN RHEUMATOLOGISTS FOLLOW THE EULAR RECOMMENDATIONS FOR THE MANAGEMENT OF RHEUMATOID ARTHRITIS WHEN MAKING THERAPEUTIC DECISIONS?
Authors: Y. Meissner, D. Huschek, A. Zink, J. Kaufmann, M. Bohl-Buehler, A. Strangfeld
Journal: Annals of the Rheumatic Diseases (2022)

Background EULAR developed recommendations for the management of rheumatoid arthritis (RA) suggesting treatment escalation and changes at different stages of the disease to reach at least low disease activity with latest updates in 2013 (1) , 2016 (2) , and 2019 (3) . The recommendation to consider adding a biologic disease-modifying anti-rheumatic drug (bDMARD) – or, since 2016, a Januskinase inhibitor (JAKi) – after the first conventional synthetic (cs) DMARD had failed and if poor prognostic factors (PPF) are present, was strengthened 2019. Since then, it is recommended that a bDMARD or a tsDMARD should be added . Objectives How closely are EULAR recommendations followed in daily rheumatologic practice in Germany? Methods Data were used from the long-term observational cohort RABBIT, which enrols patients with RA starting a bDMARD or JAKi, or a csDMARD after at least one previous csDMARD failure. According to the publication of the recommendations, periods from [I] 01/2014 – 12/2016, [II] 01/2017 – 06/2020 and [III] 07/2020 – 04/2021 were investigated. Patients who were in at least moderate disease activity (DAS28≥3.2) were selected and analysed, if they started a csDMARD, a bDMARD or a JAKi. Patients were further stratified by prior treatments and by the presence of PPF (≥4 swollen joints, positive rheumatoid factor or ACPA, erosions). Results Of the 15,150 patients with RA enrolled since 2007, 2,922 treatments were initiated in period [I], 4,580 in [II] and 415 in [III] (see Table 1). The proportion of patients with 1 previous csDMARD and ≥1 PPF who – in agreement with the recommendations – switched to bDMARD or JAKi, increased from 30% (only bDMARDs) in period [I] to 68% (bDMARDs + JAKi) in [III]. The proportions were even higher in patients with 2 previous csDMARDs (86% in [I], 93% in [III]). As recommended, JAKi were used more often as first line therapy (after csDMARD) in period [III]. Table 1. Number and percentages of treatment changes at different stages of the disease. Patients with 1 previous csDMARD &amp; no PPF 1 previous csDMARD &amp; ≥1 PPF 2 previous csDMARDs 1 previous bDMARD/ JAKi ≥2 previous bDMARDs/ JAKi EULAR Recommendation change/add csDMARD add bDMARD/ JAKi** add bDMARD/ JAKi change to another bDMARD/JAKi Total numbers of treatment changes 61 2073 2220 1700 1863 Period [I] n=25 n=848 n=986 n=543 n=520 01/2014 – 12/2016* N=2,922 csDMARD 21 (84.0%) 594 (70.0%) 134 (13.6%) 199 (36.6%) 275 (52.9%) bDMARD 4 (16.0%) 254 (30.0%) 852 (86.4%) 344 (63.4%) 245 (47.1%) Period [II] n=32 n=1,090 n=1,136 n=1,054 n=1,268 01/2017 – 06/2020 N=4,580 csDMARD 16 (50.0%) 469 (43.0%) 96 (8.5%) 261 (24.8%) 274 (21.6%) bDMARD 13 (40.6%) 509 (46.7%) 822 (72.4%) 403 (38.2%) 288 (22.7%) JAKi 3 (9.4%) 112 (10.3%) 218 (19.2%) 390 (37.0%) 706 (55.7%) Period [III] n=4 n=135 n=98 n=103 n=75 07/2020 – 04/2021 N=415 csDMARD 0 43 (31.9%) 7 (7.1%) 15 (14.6%) 9 (12.0%) bDMARD 1 (25.0%) 64 (47.4%) 60 (61.2%) 36 (35.0%) 23 (30.7%) JAKi 3 (75.0%) 28 (20.7%) 31 (31.6%) 52 (50.5%) 43 (57.3%) EULAR treatment recommendations are indicated in green. * JAKi were not available. ** Recommendation in period [I]: Addition of a bDMARD should be considered; in [II]: Addition of a bDMARD or a tsDMARD should be considered, current practice would be to start a bDMARD; in [III]: a bDMARD or a tsDMARD should be added. PPF, poor prognostic factor. Conclusion JAKi have become more established, especially in bionaive patients, but have not reached the significance of biologics in certain patient groups. The early decision for a bDMARD or JAKi has been made more frequently in recent years, yet one third of patients did not receive the recommended treatment escalation. We cannot conclude from the data, which considerations led to the decision not to escalate. Of note, German rheumatologists should rather follow the German treatment guidelines (4 ) , which are, however, very similar to the EULAR recommendations. References [1] PMID: 24161836; [2] PMID: 28264816; [3] PMID: 31969328; [4] PMID: 29968101 Acknowledgements RABBIT is supported by a joint, unconditional grant from AbbVie, Amgen, BMS, Fresenius-Kabi, Galapagos, Hexal, Lilly, MSD, Pfizer, Roche, Samsung Bioepis, Sanofi-Aventis, VIATRIS and UCB. Disclosure of Interests Yvette Meissner Speakers bureau: Pfizer, Doreen Huschek: None declared, Angela Zink Speakers bureau: AbbVie, Pfizer, Roche, Sanofi, Jörg Kaufmann: None declared, Martin Bohl-Buehler Speakers bureau: Speaker for several companies in unrestricted educational programs, each of them unrestricted state-of-the-art-talks., Consultant of: PreviPharma, basic research in osteology, no overlap with rheumatological diseases, Anja Strangfeld Speakers bureau: AbbVie, Amgen, BMS, Celltrion, Janssen, Lilly, Pfizer, Roche, Sanofi, UCB.